The findings of the re-licensure survey, conducted 06/26/23 through 06/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 06/29/23, conducted 12/19/23 through 12/20/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause and resident-to-resident altercations were promptly investigated to rule out abuse or neglect and reported to the local Senior and People with Disabilities (SPD) office when required, for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2021 with diagnoses including Alzheimer's disease, alcoholic polyneuropathy and anxiety.

The resident's service plan, dated 05/18/23, progress notes dated 03/26/23 through 06/26/23, temporary service plans, and incident reports were reviewed. The records indicated the following two injuries of unknown cause were not investigated to rule out abuse, and were not reported to the local SPD office:

* 06/01/23 - While giving Resident 2 a snack, staff discovered a small skin tear on his/her left arm which was bleeding; and

* 06/24/23 - While checking on Resident 2 in his/her room, staff discovered a skin tear on his/her right arm.

Interviews with staff members and observations of the resident indicated s/he had severe cognitive impairment and was unable to effectively communicate verbally. In both instances, Resident 2 was unable to explain how the injuries occurred.

In an interview on 06/27/23 Staff 1 (ED) confirmed the injuries of unknown cause had not been reported to the local SPD office. The facility was asked to report both incidents to the SPD office. A confirmation of the reports was provided to the survey team prior to exit.

On 06/29/23 the need to ensure all injuries of unknown cause were promptly investigated to rule out abuse or neglect, and reported to SPD when required was discussed with Staff 1, Staff 2 (RN), and Staff 4 (Assistant Director). The staff acknowledged the findings.

3. Resident 1 was admitted to the memory care facility in 09/2017 with diagnoses including vascular dementia.

Resident 1's progress notes dated 03/30/23 through 06/26/23 and an incident report dated 04/03/23 were reviewed during the survey and revealed the following:

* 04/03/23 - "[an unsampled resident] pushed the wheelchair up to the table and bumped [Resident 1's] shin on a chair, causing a skin tear."

On 06/28/23 at 3:16 pm, the resident-to-resident altercation was reviewed with Staff 1 (ED), and proof of notification to the Senior and People with Disabilities (SPD) office was requested. Staff 1 confirmed the resident-to-resident altercation had not been reported to the local SPD office.

On 06/28/23, Staff 1 was asked to report the altercation to the local SPD office. Verification the incident had been reported was received on 06/29/23.  

The need to ensure all resident-to-resident altercations were reported to the local SPD office was discussed with Staff 1, Staff 2 (RN) and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2023 with diagnoses including traumatic brain injury and ruptured aneurysm.

An incident report dated 05/25/23 and progress notes from 03/25/23 through 06/23/23 were reviewed.

Progress notes identified the following resident-to-resident incidents of abuse or suspected abuse:

* 04/05/23 - Resident 3 walked up behind another resident and pulled up their nightgown;

* 05/04/23 - Resident 3 was observed trying to lift other residents;

* 05/04/23 - Resident 3 was seen "pushing food into another resident's mouth";

* 05/04/23 - Resident 3 continued to grab residents and pull them wherever s/he was going;

* 05/04/23 - Resident 3 continued to try to feed residents and "kinda shove food in there [sic] mouth when the resident already has food in there [sic] mouth";

* 05/18/23 - Resident 3 grabbed residents, tried to pull them in their rooms, and tried to lift them;

* 05/25/23 - Resident 3 lifted a resident, and when instructed by staff to put the resident down, let go of the resident, causing him/her to land on his/her knees; and

* 06/09/23 - Resident 3 pushed another resident into a corner and would not let him/her go.

There was no documented evidence the facility reported the incidents of abuse or suspected abuse to the local Seniors and People with Disabilities (SPD) office. Staff 1 (ED) confirmed she was unaware of all the incidents except for the one on 05/25/23, and was not aware of the need to report the incident of 05/25/23 because there was no injury.

Reporting of the incidents was requested by this surveyor and proof of reporting was provided on 06/27/23 and 06/28/23.

The need to ensure all incidents of abuse and suspected abuse were promptly investigated and immediately reported to SPD was discussed with Staff 1, Staff 2 (RN), and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

C231 OAR 411-054-002831 Reporting & Investigating Abuse-other Action

1. Actions to be taken to correct the rule violation include:

Facility will review daily of all progress notes to ensure documentation is accurate, reportable events are reported. During survey it was founded in the documentation that there were reportable events for Residents 1-3. They were brought to the Executive Directors attention. These resident to resident were reported immediately via email, and phone. APS did indeed respond receiving self report. Emails were printed off and given to surveyor to confirm.

b. Incident reports will be written during staffs documentation while on shift to keep from missing a reportable event.

c. Staff will attend a all staff meeting on 7/21/2023  to review and discuss Abuse reporting and investigation guide.

d. The facility Administrator and nurse will be responsible to report all reportable incidents to local APS at 541-278-4161, and/or email District12.APSmailbox@dhsohga.state.or.us

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2023 with diagnoses including traumatic brain injury and ruptured aneurysm.

The resident's most recent service plan, dated 06/12/23, was reviewed and staff were interviewed. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Cues for showering;

* Shower schedule;

* Behavior management for the protection of other residents;

* Behaviors toward staff;

* Behaviors toward other residents; and

* OT, PT, and speech therapy services.

The need for service plans to be reflective of the resident's current care needs and provide clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 07/2021 with diagnoses including Alzheimer's disease, hypertension and anxiety.

Review of Resident 2's most recent service plan, dated 05/18/23, temporary service plans, incident reports and interviews with staff indicated the service plan was not reflective and did not provide clear direction to staff in the following area:

* Clinical records for Resident 3 documented a resident-to-resident altercation with Resident 2 on 06/09/23. There was no documented evidence of this incident in Resident 2's records, and no instruction for staff included in the resident's service plan.

In an interview on 06/29/23, Staff 1 (ED) acknowledged the facility's failure to address the altercation in Resident 2's service plan.

On 06/29/23, the need for service plans to be reflective of the resident's current care needs and provide clear instruction to staff was discussed with Staff 1, Staff 2 (RN) and Staff 4 (Assistant Director). They acknowledged the findings.

C260 OAR 411-054-0036 (1-4) Service Plan General

1. Actions to be taken to correct the rule violation include:

a.Resident #3 care plan was updated during survey to reflect the the resident's care updated person centered with individual preferences and care needs. To address all changes but not limited to;

* cues for showering;

*shower schedule;

*behavior management for the protection of other residents; and

* Behaviors towards staff;

* Behaviors towards other residents; and

*OT,PT and speech therapy services.

The administrator & Nurse will be responsible to make sure the service plans are complete with all current care needs for staff to have clear instructions.

1. Resident #3 service plan needs to be more reflective and clear intructions given to staff to provide the upmost care.

New discovery of information in regard to Behaviors it had been implemented on 5/12/2023. However it was a software glitch where it did not carry over on 6/12/2023 newest service plan. Addition during service plan meetings the R.N., and Executive Director will implement all, and current care needs to service plans during service plan meetings to be reflective of current needs.

2. Resident #2 service plan was not reflective  and did not provide clear instructions to staff.

a. Service plan has been updated with information of resident to resident with resident#3 for history of .

b. The Executive Director and R.N. will implement any said changes when they occur. In order for staff to have reflective, and clear directions.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by an RN for 1 of 3 sampled residents (#1) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the memory care facility in 09/2017 with diagnoses including vascular dementia and hypertension.

a. Progress notes dated 03/30/23 through 06/26/23, an incident report dated 05/13/23, outside provider documentation, the quarterly evaluation dated 06/21/23 and the service plan dated 06/23/23 were reviewed and revealed the following:

* 05/13/23 - Progress note stated, "Hospice came at 5 pm and checked on [Resident 1] and [s/he] did say [s/he] had a stroke";

* 05/17/23 - HH RN stated, "[Resident 1] had probable [cerebrovascular accident] over weekend. [Right] side weak, arm [right] flaccid"; and

* 05/17/23 - Facility RN stated, "Earlier in day [Resident 1] was noted to have [right] side facial drooping and inability to move [right lower extremity] and [right upper extremity]."

Interviews with staff and observations of Resident 1 confirmed s/he could move all extremities prior to 05/13/23 and now presented with right extremity and facial weakness.

A stroke or sudden and lasting loss of strength in both the upper and lower extremities indicated a significant change of condition and required an RN assessment.

An RN assessment for the significant change of condition was requested on 06/27/23 at 12:04 pm. The facility provided an incident report dated 05/17/23, progress notes dated 05/22/23, and a quarterly evaluation dated 06/21/23. The RN assessment was initially documented on 05/17/23 or four days following the significant change of condition. Staff 2 (RN) confirmed no additional documentation on 06/28/23.

The facility failed to ensure an RN assessment was completed in a timely manner following a significant change of condition.

b. Resident 1's weight records were reviewed and revealed the following:

* 04/11/23 - 100 pounds;

* 05/12/23 - 106.5 pounds;

* 06/13/23 - 97 pounds; and

* 06/23/23 - 95 pounds.

From 04/11/23 to 05/12/23 the resident had a weight gain of 6.5 pounds or 6.5% of his/her body weight in one month. This weight gain constituted a significant change of condition and required an RN assessment.

An RN assessment for the significant weight gain was requested on 06/27/23. Staff 2 (RN) confirmed on 06/28/23 that no RN assessment for the weight gain had been completed.

There was no documented evidence the facility RN completed an assessment of Resident 1's significant weight gain.

The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

C280 OAR 411-054-0045 (1)(a-f)(A)(C-F)

Resident health Services

1.Actions to be taken to correct the rule violation include:

a.) Resident #1 will have a significant change of condition assessment in a timely manner. It was acknowledged however R.N. did not make a note stating signicant change of condition. Documentation was in place. R.N.& Executive Director will be responsible to make sure all appropiate documention is in place moving forward.

b.) Resident #1 it was revealed that a significant change of condition was needed for weightloss. The R.N. will keep a log of all residents weights. This will help with monitoring of weights that may need a significant change of condition.

c.) The Executive Director and R.N. will meet daily during morning meeting to monitor resident documentation to ensure that significant change of condition are done timely.

d.) A website was also

provided in card form for the R.N. to refer to for such education. The R.N. will utilize this material to keep in compliance with such areas.

Based on interview and record review, it was determined the facility failed to have a protocol to facilitate the receipt of information from off-site health service providers for residents, include information obtained from the provider in the resident's record, and adjust the resident's service plan as applicable, for 1 of 2 sampled residents (#3) who received health care services from outside providers. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2023 with diagnoses including traumatic brain injury and ruptured aneurysm.

During the acuity interview the resident was identified as currently receiving physical therapy (PT), occupational therapy (OT), and speech therapy (ST).

The resident's records included a three month PT/OT/ST schedule from an outpatient rehabilitation department. In an interview on 06/27/23, Staff 1 (ED) reported Resident 3 received outpatient therapies two times per week based on the schedule in the resident's chart. When asked for documentation of the therapy sessions, including any therapist recommendations, she reported the facility did not have any documentation of the therapy sessions.

In an interview with Resident 3's sister on 06/28/23, she reported the resident was discharged from PT/OT/ST three weeks prior, after having received therapies twice a week for several weeks, then once a week for several weeks. She reported discharge recommendations had been emailed to the facility, per the speech therapist. Discharge summaries were requested from Staff 1 who stated she did not know if the facility had received them, but she would obtain them.

During survey, Staff 1 provided outpatient therapy discharge summaries dated 06/06/23 with a fax time stamp of 06/29/23. All three therapists referenced home programs for the resident which were not included in the resident's record with adjustments to the resident's service plan as applicable.

The need to ensure the facility had a system for coordinating care with off-site health service providers was discussed with Staff 1, Staff 2 (RN), and Staff 4 (Assistant Director) on 06/29/23. They acknowledged they needed to improve their coordination of care with off-site health service providers.

C-290 OAR 411-054-0045 (2) RES Hlth Srvc:

On and off-site Health Srvc

1.)Actions to be taken to correct the rule violation include:

a.) It was founded that resident #3 receives outside services for PT/OT/ST however no notes were given. Requested such documents and additionally found out these services were ended. Moving forward these such services were to be added to his service plan.The R.N. and Executive Director will monitor such services once initiated. They will be added to service plan, and monitored as per schedule of services, and return from appointment for any new findings.

b.) All PT/OT/ST outside services will be documented as a appointment to a provider. Required documentation is a physican visit form to be sent with the resident at the time of appointment. It will be returned to facility after appointment. If such documentation is not returned the facility will request it.

b.) Upon Receipt of physican visit form from outside provider visit. The R,N. will review for any recommendations. R.N. will implement, and initial that she received and reviewed.

c.) The Executive Director, and R.N. will be responsible for obtaining this information for any resident that is receiving outside services.

Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as required in OAR 411-054-0050. Findings include, but are not limited to:

In an interview on 06/28/23, Staff 1 (ED) reported Staff 2 (RN) was the facility's designated Infection Control Specialist.

Review of Staff 2's infection control training revealed she had not completed the required specialized Department-approved training in infection prevention and control protocols for an assisted living facility Infection Control Specialist.

The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 and Staff 2 on 06/29/23. They acknowledged training had not been completed as required.

C295 OAR 411-054-0050 (1-5) Infection control Prevention & Control

1.Actions to be taken to correct the rule violation include:

a.) The R.N. is our Infection Control Specialist. The R.N. does possess Nursing Home Infection Preventionist training course, however it does not meet the CBC requirements.The R.N. has completed the required training from OCP, and is in place.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#2) who were prescribed psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2021 with diagnoses including Alzheimer's disease, alcoholic polyneuropathy and anxiety.

Review of Resident 2's MAR, dated 06/01/23 through 06/26/23, and physician orders revealed the following:

* Resident 2 was prescribed PRN lorazepam for anxiety, and it was administered to the resident on three occasions between 06/15/23 and 06/20/23.

The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications, and the MAR lacked information on non-pharmacological interventions to attempt.

In an interview on 06/27/23, Staff 2 (RN) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        On 06/29/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2, and Staff 4 (Assistant Director). They acknowledged the findings.

C330 OAR 411-054-0055 (6) Systems:

Psychotropic Medication

1.)Actions to be taken to correct rule violation include:

a.)Resident #2 was prescribed a PRN Lorazepam for anxiety. Non- pharmacological interventions were entered. Order was received the day of survey for a decrease in medication.R.N. has clear knowledge that interventions will need to be added on MAR & service plan as soon as received.

b.) During initial evaluation prior to move-in the question will be asked if said potential resident is receiving psychotropic PRNS. In order to add non-pharmacological interventions to service plan, and MAR.

c.) The R.N. will review all received orders to implement any psychotropic PRNS non-pharmacological interventions to MAR & Service plans. After completion the R.N. will initial order and put in residents file for task completion.

d.) The R.N. and Executive Director will be responsible for implementing non-pharmacological interventions. Additionally Executive Director & R.N. will review MAR on a daily basis to ensure MTs are documenting and following interventions.

F. This will be reviewed with all MTs on 7/21/2023 training for non-pharmacological interventions with the R.N. & Executive Director.

Based on interview and record review, it was determined the facility failed to provide a sufficient number of direct care staff to meet the 24 hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:

During an interview on 06/26/23, Staff 1 (ED), reported the posted staffing schedule included a staff member who was a caregiver who floated between the memory care facility and the assisted living facility, two separate licensed facilities.

During an interview on 06/27/23, Staff 9 (Care Partner), reported she was the float caregiver for the day.

During an interview on 06/27/23, Staff 1 stated she was not aware the facility was not allowed to share staff with the other separately licensed facility.

The need to ensure the facility provided a sufficient number of direct care staff to meet the 24 hour scheduled and unscheduled needs of residents, was discussed with Staff 1, Staff 2 (RN) and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

C360 OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

1.)Actions to be taken to correct rule violation include:

a.) Executive Director requested an exception from the policy analyst. Until received will not share staff.

b.) The Executive Director will contnue to hire staff for both units.

c.) The Executive Director will be responsible not to share the floating staff unitl the  receipt of approval from the Policy Analyst.

Based on interview and record review, the facility failed to review the Acuity-Based Staffing Tool (ABST) following a significant change of condition and no less than quarterly. Findings include, but are not limited to:

On 06/28/23 at 8:47 am, the ABST was reviewed with Staff 1 (ED) and revealed the following:

a. Resident 1 admitted to the facility in 09/2017 and had a significant change of condition on 05/13/23. The resident's ABST was last updated on 07/17/22 which indicated it had not been updated quarterly or following the significant change of condition.

b. Resident 2 was admitted to the facility in 07/2021 and his/her ABST had not been reviewed and updated quarterly since 07/17/22.

c. The ABST for ten unsampled residents had not been reviewed or updated quarterly. Seven of the ten unsampled residents' ABST had not been updated since 07/2022.

The need to ensure the facility's ABST was updated following a significant change of condition, and no less than quarterly was reviewed with Staff 1, Staff 2 (RN) and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

C361 OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool

1.)Actions  to be taken to correct rule violation include:

a.The ABST tool will need to be monitired weekly if not daily to make sure it is at the most accurate and up to date.

b.) ABST is being updated currently for in acuurate and previous updates, along with quarterly updates during service plan meetings.

c.) The Executive Director & R.N. will be responsible at the 30 days, and quarterly service plan meetings to update ABST for all residents moving forward.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 231, C 295, C 360, C 361.

Z142 OAR 411-057-0140 (2) Administration Compliance

Refer to C 231, C295, C360, C361

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260, C 280, C 290, C 330.

Z162 OAR 411-057-0160 (2b) Compliance with Rules Health care

Refer to C260, C280, C290, C330

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed based upon the resident's preferences and needs, and was included in the service plan for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2017 with diagnoses including vascular dementia.

Review of the resident's nutrition and hydration plan in the 06/23/23 service plan revealed it failed to identify the resident had experienced significant weight changes between 04/11/23 and 06/13/23, failed to provide clear instruction to staff related to the resident's abilities, failed to include the use of straws as adaptive equipment, and failed to identify specific preferences for food provided by the facility kitchen.

The need to ensure an individualized nutrition and hydration plan for each resident was developed based upon the resident's preferences and needs, and was included in the service plan was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 4 (Assistant Director) on 06/29/23. They acknowledged the findings.

Z163 OAR 411-057-0160 (2)(c)(A)(B) Nutrition and Hydration

1.) Actions to be taken to correct rule violation include:

a.) Resident #1 passed away during survey. We were not able to update her service plan for nutrition and Hydration. However if this did not occur it was to be implemented to reflect such need.

b.) During admission a dietary form will need to be filled out for all admits of meal preferences of likes and dislikes this information will be added to the service plan, and any special untensils if utilized.

c. During admission, 30 day, and quarterly sevice plan meetings the R.N. & Executive Director will monitor service plan and dietary sheets to make sure hydration and nutrition preferences are accurately documented and followed.

d.) The Executive Director, and R.N. will be responsible for this information to be added to the service plan along with dietary sheets a completely filled out for each individual.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of or inside their rooms. Findings include, but are not limited to:

During the survey, observations revealed multiple resident rooms were locked from the outside which prevented residents from entering or leaving their rooms independently. Caregiving staff carried a key which could open residents' rooms, and caregivers provided prompt assistance when residents requested to go to their rooms.

On 06/26/23 between 2:11 pm and 3:09 pm, Staff 6 (Care Partner) and two other staff members were observed unlocking resident rooms with a key and then entering to provide care. The apartments that required keyed entry included rooms 202, 203, 204 and 209. This surveyor visualized a resident resting in room 204 after caregivers unlocked the door. At 3:11 pm on 06/26/23, apartments 208, 211 and 212 were observed to be locked from the outside.

In an interview with Staff 1 (ED) on 06/27/23 at 9:55 am, she reported it was facility policy to not lock resident room doors and she would speak to staff immediately about following this policy. Rooms were observed to be unlocked for remainder of the survey.

The need to ensure residents were not locked out of or inside their rooms was discussed with Staff 1, Staff 2 (RN) and Staff 4 (Assistant Director on 06/29/23. They acknowledged the findings.

Z176 OAR 411-057-0170(9) Resident Rooms

1. Actions to be taken to correct rule violation:

a.) Rooms were unlocked immediately for residents to be able to enter and exit their apartment at any given time.

b.) Staff will not lock, and or unlock any apartments unless the resident locks themselves. Staff will still knock and wait for an ok to come in from the resident if know answer staff will open door, and announce themselves before fully entering all the way.

c. The Executive Director, and R.N. will monitor and discuss with the staff at daily morning meetings, and along at shift change for the  not locking of apartments.

d.) The Executive Director will review and be responsible for staff at the upcoming staff meeting on 7/21/2023 for the locking and unlocking apartments.

C999 Technical Assistance

C242 Resident Services: Activities OAR 411-054-0030

1.)Actions to be taken to correct rule violation include:

a.) Life Enrichment will be responsible to plan more activities with shorter time frames, but more activities through out the day. This will help to leviate behaviors, and or engaging rather than wandering.

b.) The Executive Director along with Life enrichment coordinator will be responsible to implement such schedule.

C303 OAR 411-054-0055 (1)

1.) Actions to be taken to correct rule violation include:

a.) The Executive Director & R.N. will hold a meeting with all Med Passers in regard to Medication Administration recording.

b. R.N. will review MAR on a daily basis to audit MAR for missing documentation.

c.) The R.N. will additionally fill out a form for drop charting. The staff will follow up as directed on form for any missing documentation.

c.) The executive Director, and R.N. will be responsible that this task is completed.